Surgical indications in comatose patients with an acute subdural hematoma: A prospective study of 65 patients

Introduction: Surgery has been considered for years as the only treatment for posttraumatic acute subdural hematomas over 3-4 mm of thickness. Case reports and recently published series show how, in a few selected patients, the hematoma can be reabsorbed with a conservative management under adequate monitoring. Materials and Methods: From January 1, 1994 to May 31, 1996, we admitted 65 comatose (GCS < 8) patients harbouring acute subdural hematomas 5 mm thick or more. There were 45 males and 20 females, average age was 54 yrs and the cause of trauma was RTA in 45 (70%) cases. We have prospectively decided to initially conservatively treat the following cases: a) GCS stable or improving b) Hematoma thickness of less than 10 mm and midline shift of less than 5 mm c) ICP of less than 20 mm Hg d) A second CT examination was always repeated within 12 hours from injury. Results: Out of 65 cases, 14 patients fulfilled these criteria and were initially managed non surgically. No statistically significant differences were seen concerning average age, GCS on admission, presence of pupillary abnormalities. As obvious, hematoma thickness (p < 0.0001), midline shift (p < 0.05) and mean ICP (p < 0.05) were reduced in the conservatively treated patients. Hematoma reabsorption was visible on repeat of CT in all of the cases within 48 hrs and in 6 cases already within 6 hours from injury. The outcome of the non surgical group was 9 cases of functional recovery (GR + MD) out of 14 patients whereas in the surgical group were only 14 cases of functional recovery out of 51 patients (p < 0.02). In conclusion initial non surgical management of a selected subgroup of subdural hematoma patients using a combination of ICP monitoring and repeat of CT seems to be reasonably safe.